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Message from the chair: Preterm Labor Assessment Toolkit

Laurie C. Gregg, MD

In a hospital with 40 ob-gyn providers, there can be 40 different ways to triage a patient presenting with preterm contractions. The variation in the assessment of preterm contractions, which has been documented in scientific publications, can lead to avoidable adverse outcomes and unnecessary interruption to a pregnant patient’s normal life.

More than 75% of patients presenting with preterm contractions deliver at term, yet 25% of preterm neonates do not receive antenatal corticosteroids. Some very low birth weight babies deliver at a facility unable to care for them.

Hospitals in California have the opportunity to improve the triage of these patients by implementing standardized preterm labor assessments. The Preterm Labor Assessment Toolkit (PLAT), initially developed at Sutter Medical Center, Sacramento, and published by the March of Dimes, is supported by the ACOG Committee on Obstetric Practice and complements the ACOG Practice Bulletin “Management of Preterm Labor” by providing algorithms and order sets for a hospital triage area. In addition to improving outcomes of preterm neonates and appropriately discharging pregnant patients who are low-risk for preterm labor, most hospitals that use the toolkit see cost savings as door-to-discharge time is four hours or less.

Before I began using this assessment tool, I often kept patients with preterm uterine contractions for evaluation for hours or days and had them back in the office frequently. I also would have two to three calls and one visit to the triage area to assess a preterm patient with contractions. Now, with the standardized protocols, many times one call to discuss results of the assessment and disposition is all it takes. The toolkit helps give moms and babies better outcomes in less time. Why wouldn’t hospitals implement PLAT? PLAT makes good sense, both practically and scientifically.

District IX will assist in the dissemination of PLAT information and hospital implementation through regional training sessions and at hospitals that request a speaker. Be on the lookout for more information. You should be able to request a speaker at the beginning of April.

Encourage your labor and delivery triage area to implement PLAT. You and the moms and babies of California will benefit.

There is ample evidence that physician burnout, psychological distress, or mental illness and the factors that contribute to these states have significant adverse impacts on the delivery of quality health care and patient safety. The underlying contributory elements include long work hours, emotionally charged work environments, rapid shifts in the health care landscape, bureaucratic rigmarole, and, finally, organizational culture that does not promote or support physician self-care efforts.

How many of us have continued to work during chemotherapy, shortened our maternity leave, or grieved the loss of a loved one while on call? Who among us can say we have never resented a colleague who demonstrated self-care because it had an impact on our work load? Physicians are more likely to commit suicide than the general population and suffer significant rates of depression and substance abuse. Furthermore, physicians ignore their own regular preventive care and delay medical care or self-treat in urgent circumstances. If we recommend stress reduction, exercise, healthy eating, or allowing time to heal after illness or surgery for our patients, then why not for ourselves?

The health and wellness of physicians is paramount to effective and optimal patient care. So, shouldn’t it be valued as much as financial productivity and measured along with all the other quality indicators in a health system? The authors of a 2009 article in The Lancet believe it should. If you’re interested in learning more about this topic, I suggest you read the article: “Physician wellness: A missing quality indicator.”

There are validated instruments to measure burnout and standardized questionnaires that can measure wellbeing in a health care setting. To date, however, there is only preliminary research into specific strategies that improve physician wellbeing. One of those strategies being evaluated and showing promise is training physicians in mindfulness. The District IX Committee on Physician Work-Life Balance will promote seminars and presentations by internal and external experts over the next few years. We look forward to your interest and participation.

California Maternal Quality Care Collaborative works to improve care for mothers and newborns

The California Maternal Quality Care Collaborative (CMQCC) released its new Preeclampsia Toolkit on January 16. The toolkit was developed by the CMQCC Preeclampsia Task Force, a multidisciplinary committee of experts, co-chaired by ACOG District IX Fellows Maurice Druzin, MD, and Laurence Shields, MD, and CMQCC Clinical Director Nancy Peterson, RNC, PNNP.

The primary aim of the toolkit is to guide and support obstetric providers and health care organizations in developing processes for timely recognition and an organized response to preeclampsia. A highlight of the toolkit is the identification of triggers, or clinical warning signs, that require immediate evaluation and communication with the provider, whether they occur in the prenatal clinic, in the emergency room, during labor and delivery, or postpartum.

Coinciding with the release of the toolkit, the Centers for Medicare & Medicaid Services-funded Partnership for Patients is spearheading new activities to improve care for preeclampsia and obstetric hemorrhage nationwide. More than 150 California hospitals are involved in one of the Partnership’s Hospital Engagement Networks (HENs), operated by California’s Hospital Quality Institute (HQI), Dignity Health, or Intermountain Healthcare.

CMQCC collaborated with ACOG and the Association of Women’s Health, Obstetric, and Neonatal Nurses to develop quality measures to be used by several of the HENs to evaluate care improvements for preeclampsia and obstetric hemorrhage. CMQCC will work with District IX to develop educational support for the hospitals involved in the HEN operated by HQI.

CMQCC will also supportthe data collection and quality improvement activities of these hospitals through its California Maternal Data Center (CMDC). CMDC is a dynamic online tool that provides rapid-cycle data for hospital activities to improve clinical quality across a wide range of areas, including care for preeclampsia, labor management, and identification of non-medically indicated early elective deliveries.

CMDC uses existing sources of data to calculate dozens of hospital- and physician-level metrics, benchmarking statistics, and drill-down information. The rapid-cycle metrics are presented in an interactive and easy-to-use tool that can be used by clinicians, managers, hospital administrators, and public health professionals. Fifty California hospitals are already participating in CMDC, and more than 30 additional hospitals are poised to join this year.

In addition to providing support for hospital quality improvement, CMDC supports numerous research and collaborative projects, including a US Department of Health and Human Services-funded severe maternal morbidity validation study and a Los Angeles County project testing new models of prenatal care delivery. To learn more about your hospital’s participation in CMDC, please contact Anne Castles at acastles@cmqcc.org.

Junior Fellow news

Stacy E. Wilson, MD, District IX Junior Fellow chair

District IX Junior Fellows thrived in 2013. Section leaders gave “Introduction to ACOG” presentations to the residency programs in their geographic locations. This initiative has improved resident involvement in ACOG activities and publicized the invaluable educational resources ACOG offers to students and residents in training.

District IX Junior Fellows were well represented at the Annual District Meeting in September. Several Junior Fellow activities took place at the meeting, including a young physician mentoring and leadership forum, Junior Fellow vs. Fellow trivia competition, and personal oral case list review session. Katherine A. Hartzell, MD, a fourth-year resident at the University of California, San Diego, won the District IX Junior Fellow Prize Paper Award, after delivering a stellar oral presentation.

Advocacy in women’s health and medicine is a top priority for Junior Fellows in California. District IX Junior Fellow section vice chairs attended the Junior Fellow Section Officer Leadership Development Program on March 1, prior to the ACOG Congressional Leadership Conference, March 2–4, in Washington, DC.

The District IX Executive Committee recently approved our proposal to create a Junior Fellow legislative chair position. We are pleased to welcome Yen Truong, MD, to the Junior Fellow Advisory Committee to fill this role. In addition to helping plan and support resident attendance at our Lobby Day in May, Dr. Truong will participate in weekly legislative calls and serve as an expert to lobbyists as needed.

Looking ahead to the upcoming year, District IX Junior Fellow leaders will remain committed to supporting medical student recruitment and promoting ACOG initiatives. We plan to highlight the Junior Fellow Congress Advisory Council’s Social Media and Professionalism in the Medical Community video in future “Introduction to ACOG” presentations to educate young physicians about how easy it is for a simple social media overshare to be considered a serious HIPPA violation.

District IX Junior Fellow section leaders will continue to investigate and report on local program success stories, including resident research publications, robotic training opportunities, international health rotations, contraception outreach programs, community service projects, and career-planning seminars. One goal for 2014 is to design a district-wide service project that will help support local communities in women’s health education as well as promote resident and medical student involvement in ACOG.

With the new year, California’s health benefit exchange, Covered California, is in full swing. As of December 31, the exchange had enrolled roughly 500,000 individuals, accounting for nearly a quarter of all exchange enrollments nationwide.

For those unfamiliar, Covered California is a marketplace for health insurance products, not an insurer. It offers insurance products that qualify individuals for federal premium subsidies. Because Covered California is a marketplace, products offered through it generally should be thought of as commercial health insurance products as opposed to public coverage with a set fee schedule.

Covered California, however, has also taken on the role of active purchaser, meaning that it will behave much like a large employer negotiating coverage terms (eg, premiums and patient cost-sharing) on behalf of its employees. This detail, coupled with requirements in federal and state law, creates a number of important considerations for physicians participating in exchange plans.

That being said, whether your practice is participating or not, here are 10 things to know and do as we move forward with Covered California:

1. Verify your participation status and information in Covered California’s central provider directoryThough the directory has improved significantly, the California Medical Association (CMA) continues to find errors in the information listed. Members have reported errors in their participation status, board certification, languages spoken, address, and specialty. Indeed, in the first weeks of the directory’s existence, the specialties of ophthalmology and ob-gyn were inversed for a number of physicians. To verify your status, follow the directions found in CMA’s “Surviving the First Month of Covered California.”

2. Review any contracts or contractual amendments for exchange participation
If you are participating in Covered California, it may be helpful to undertake a review of any exchange-specific contract provisions, such as exchange-specific rates and policy manuals that may be incorporated by reference. If questions arise, ask the plan-specific contact listed in CMA’s “Surviving the First Month of Covered California.”

3. Be aware of off-exchange products that use exchange plan networks
Every plan offered in the exchange must also be offered outside of the exchange, using the same network. This requirement has resulted in a number of practices unknowingly seeing patients out of network for commercial products that use an exchange network, as these identification cards do not have the Covered California logo on them. For example, a Blue Shield identification card may read “individual PPO” in the upper right and list “enhanced PPO” as the product, but only upon further investigation will it show the network as “IFP off exchange,” which is an exchange network.

4. Know who can help patients get further information on and enroll in exchange plansFor practices getting exchange enrollment questions that its staff is unprepared to answer, printing out a list of nearby certified enrollment assisters may be helpful. These can be found on the Covered California enrollment assistance website.

5. Assess your practice’s policies on extending credit to and collections from patients
Some exchange plans will impose high cost-sharing burdens on patients. Furthermore, the currently evolving situation of the first month’s premium due date and delays in enrollee welcome packets may make eligibility verification difficult for some patients. Practices should consider strategies to protect themselves from such financial risks. Please refer to the CMA physician guide to Covered California for further information.

6. Be prepared for exchange patients in grace period coverage limbo
Exchange enrollees receiving subsidies, currently 85% of those in Covered California, will have three months of premium delinquency before being terminated for non-payment. If a practice renders services to these patients in the latter two months of the three-month grace period, the plan has the option to suspend payment on those claims and deny them if the patient is terminated for non-payment. California will require exchange plans to represent coverage as inactive for those patients in months two and three of the grace period and give notice to certain physicians of record as to the patient’s status. Practices should have a policy in place for when they encounter patients in this period of uncertain coverage. Please refer to the CMA physician guide to Covered California for further information.

7. Know the participation status of physicians, facilities, and other providers to which you may refer or use on a regular basis
Covered California plans require that physicians provide advance notice to patients of any out-of-network providers in the treatment plan and allow such patients to opt out of their inclusion in the treatment plan. If, however, the provider is listed as participating in the plan’s directory, the practice cannot be held liable for the inclusion. Please refer to the CMA physician guide to Covered California for further information.

8. Be aware of patient cost-sharing across exchange plansCovered California plans will expect practices to consider the cost of a treatment plan to the patient. Furthermore, treatment compliance challenges may arise among exchange patients due to high costs related to brand drugs, imaging, and specialty visits, among other things. More information can be found in the Covered California benefit summaries.

9. Let no envelope from a health insurer go unopened for too longExchange plans are continually developing critical details as to how these plans will operate, especially in the areas of claims and billing. Many of these details are likely to come via policy manual amendments, which could be in a small envelope easy to overlook. Stay up to date on such significant changes by subscribing to CMA Practice Resources, a free e-bulletin that focuses on critical payer and health care industry changes and how they directly affect the business of a physician practice.

10. Stay current on significant Covered California developments that may affect your practiceStay up to date with CMA Reform Essentials, a free e-bulletin designed to provide readers with the latest developments of California’s implementation of federal health care reform.